Application for Import Quota for Ephedrine, Pseudoephedrine, Phenylpropanolamine Worksheet A
WORKSHEET A
U.S. Department of Justice
Drug Enforcement Administration
APPLICATION FOR IMPORT QUOTA FOR EPHEDRINE, PSEUDOEPHEDRINE, AND PHENYLPROPANOLAMINE
PART 12(II)(a) – DOMESTIC DISPOSITION (SALE) / UTILIZATION
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
Email:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
If you need additional pages, please copy this one and complete.
DEA FORM 488 (Worksheet A)
(3/31/2019)
U.S. Department of Justice
Drug Enforcement Administration
APPLICATION FOR IMPORT QUOTA FOR EPHEDRINE, PSEUDOEPHEDRINE, AND PHENYLPROPANOLAMINE
PART 12(II)(a) – DOMESTIC DISPOSITION (SALE) / UTILIZATION
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
Name of Company or Manufacturer
Contact Person
Address
Telephone
FAX
DEA Registration No. (if applicable)
Email:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).
Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)
If you need additional pages, please copy this one and complete.
DEA FORM 488 (Worksheet A)
(3/31/2019)